Healthcare Provider Details

I. General information

NPI: 1225407604
Provider Name (Legal Business Name): MICHAEL ROSS CONNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 09/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 COORS BLVD NW A
ALBUQUERQUE NM
87120-1204
US

IV. Provider business mailing address

110 RICHMOND DR SE UNIT 206
ALBUQUERQUE NM
87106-2252
US

V. Phone/Fax

Practice location:
  • Phone: 505-352-1166
  • Fax: 505-352-2805
Mailing address:
  • Phone: 575-642-4779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4332
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: